Provider Demographics
NPI:1063728871
Name:SOUTHWESTERN ILLINOIS COLLEGE
Entity type:Organization
Organization Name:SOUTHWESTERN ILLINOIS COLLEGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAID SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-239-0749
Mailing Address - Street 1:718 SCHEEL ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-4159
Mailing Address - Country:US
Mailing Address - Phone:618-239-0749
Mailing Address - Fax:618-239-6232
Practice Address - Street 1:718 SCHEEL ST
Practice Address - Street 2:SUITE C
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-4159
Practice Address - Country:US
Practice Address - Phone:618-239-0749
Practice Address - Fax:618-239-6232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343800000X343800000X
IL343900000X343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6222001Medicaid